Dial L for Legislation

EMS legislation would mandate a common access number, networking of hospitals, trained paramedics and a council, reports Rita Dutta.

It is a chilling experience that everyone has faced or heard about. Somebody was wailing for urgent medical care and you were clueless on whose door to knock seeking help. There was no easy-to-remember number that you could recall. Crucial time was lost trying to hunt down the number of the family physician. Now, if you were in London, all you had to do was dial 999 and within minutes medical aid would have reached you.

Estimates say a sound EMS system reduces mortality rate of emergency cases to one third. India, which witnesses 142 deaths for every 10,000 vehicles—the highest in the world—stands as a paradox. Despite eight per cent GDP growth and percentage of paying patients increasing with the surging economy, India does not have legislation for EMS.

While a lot is to be desired, a band of committed experts are constantly lobbying with the Government for a national legislation on EMS. Legislation would mandate a common access number, formation of an EMS council, trained paramedics, gradation of ambulance and hospitals, network of hospitals and define physical and human resources needed for EMS.

Associations like Society of Emergency Medicine-India (SEMI) and American Association of Physicians of Indian Origin (AAPI) have submitted proposals of EMS legislation to the Central and State Governments of Gujarat, Maharashtra and Andhra Pradesh. Reportedly, the Gujarat Government has drafted the legislation, the bill is cleared by the cabinet and is waiting to be tabled in the next session of the State Assembly.

Explains US-based Dr S Balasubramaniam, President, AAPI, "A patient needing emergency care must have a uniform and simple access, be treated by the right person at the pre-hospital level (trained paramedics with direct supervision), transported by the right means (paramedic ambulances, not transport vehicles) to the right hospital (pre-designated hospitals Level I, II or III depending on the medical emergency) in the right time (within 20 minutes of the call for help). We need a system where everyone gets immediate medical help without doing a 'wallet biopsy' (ability to pay)."

According to Dr Prasad Rajhans, past President, Society of Emergency Medicine-India (SEMI), "Legislation would ensure that all states form an EMS network and ensure EMS reaches everybody."

A common access number

The first step towards building EMS is to establish a call centre with a common access number. Like 100 for police and 101 for fire in India or 999 for the UK and 911 for the US and 000 for Australian EMS. The need is for a three-digit easy-to-remember number which can be accessed by landline and cellphones. By dialling the number, one is connected to the call centre. There the attendant tracks the origin of call through GPS, notes down important details like name of the caller, his relationship to the accident victim, condition of the victim and the location. He then calls up the ambulance positioned nearest to the accident site and through GIS guides the ambulance to the accident site. Meanwhile, the emergency department of the hospital nearest to the accident site is informed about the arrival of the patient. The paramedics accompanying the patient are also in constant touch with the hospital through wi-fi communication about the condition of the patient.

According to Dr Paresh Navalkar, Consultant, Ambulance Access for All, Mumbai, "It is important to have the call centre manned by trained call analysers and not call centre employees. The personnel should understand the gravity of the accident and send help accordingly." Experts feel that every district need not have a call centre, one is sufficient for the entire state. For instance, for all of New Zealand, the call centre is located at Wellington.

Network of hospitals & fleet of ambulances

When every minute the condition of the patient deteriorates, manoeuvring through the infamous traffic snarls and scouting for bed vacancy in nearby hospitals is a daunting task. Thus, if we have EMS networked hospitals, thanks to constant feedback of paramedics, doctors are ready with the plan of treatment for the patient even before the patient has arrived. Says Mabel Vasnaik, Head, Department of Emergency Medicine, St Johns Medical College Hospital, Bangalore, "Hospitals should be adequately networked so that in the event of the hospital not having a vacant bed or the required facility, the patient can be sent to the right hospital instead of being shunted from one place to another."

It is important that both public and private hospitals constitute the EMS network. "Once the patient is in a state to decide, he may wish to be shifted to some other hospital, depending on affordability," reasons Dr Rajhans.

Dr Manjul Joshipura, Member of WHO's steering committee on trauma and EMS, suggests a three-tier grading for EMS networked hospitals: "Level I should be equipped to deal with all emergencies including cardio and neuro cases and have facilities like CT scan, cath labs, ICU and OT; Level II should have at least an ICU, X-ray facilities and OT, and Level III should have a blood bank and a minimum set of diagnostic facilities.”

Standardise ambulances

To complement the network of hospitals, a fleet of ambulances positioned at various parts of the city are needed exclusively for EMS. This will rule out dependence on hospital ambulances. It has often been observed that hospitals do not have ambulances to despatch for EMS work, as they have been engaged for other work.

Having a service is not enough, setting standards for its functioning is equally crucial. According to Dr Rob Russell, Senior Lecturer, Department of Emergency Medicine, Peterborough Hospital, NHS, UK, "The Government should set some realistic target for medical help to reach the casualty. In the UK, the time from the moment the call is received till help reaches the casualty is eight minutes in urban areas and 16 minutes in rural areas. Around 80 per cent of the time the ambulance service has to meet the target, failing which the NHS fines the service." Besides ambulances, the purview of EMS should also include paramedics on motorbikes. "First the help can reach on motorbikes and then by ambulance," suggests Dr Russell.

Even ambulances should be standardised and graded. "Ambulances should be categorised as 'patient transfer vehicles' for transferring ill patients, say from hospital to diagnostic centre, 'basic ambulances' for not-so-ill patients and 'advanced ambulances' for critically-ill patients. Advanced ambulance should have capabilities for intubation and ventilation, IV fluid, defibrillators, blood pressure monitor and splintages for major fractures, basic ambulance should have oxygen, IV fluid capabilities and basic blood pressure monitor, and the rest of the ambulances, which do not meet these standards, should be classified as patient transfer vehicles," suggests Dr Joshipura.

EMS Council

To monitor EMS work at various levels, standardise training programmes and ambulances and filter out malpractice, formation of an EMS council is sine qua non. Experts fear that many a fly-by-night EMS training institutes might mushroom once the EMS legislation is passed. According to Dr Suresh David, Head, Department of Emergency Medicine, CMC, Vellore, "The Council should also empower paramedics to treat patients and to administer medication without the fear of medico-legal repercussions." Members from hospitals, ambulance service, state health departments should constitute the Council with commissioner of police and fire as ex-officio members, suggest experts.

EMS courses

Despite MCI not recognising MD in emergency medicine, the Department of Accident and Emergency Medicine at the SRMC in 2000 became the first university in the country to start a formal PG programme in emergency medicine. Vinayaka Mission's Medical College in Salem, Tamil Nadu, offers similar courses. As of now, EMS training is provided at CMC, Vellore, Symbiosis Institute, Pune with affiliation with LA, and Apollo Ahmedabad with New York EMS. National Trauma Management Course by Academy of Traumatology offers trauma life support course for doctors.

Trained paramedics & technicians

Most emergency departments in India are manned by junior doctors with little expertise in managing emergencies. The lack of trained experts is attributed to the fact that emergency medicine is not yet recognised by the Medical Council of India (MCI) and there are no recognise-dtraining programmes for physicians or pre-hospital personnel.

Dr T Ramakrishnan, President, SEMI, explains, "As the legislation has not authorised paramedics to administer medicine or basic first aid to emergency patients, hospitals out of fear feel compelled to send their doctors and nurses. Why waste doctors on something which can be handled by paramedics?"

SEMI wants the Ministry of Health and MCI to recognise the discipline and institute more courses in various medical colleges in our country.

AAPI has been instrumental in setting up various standardised courses. It introduced formal American Heart Association (AHA) Lifesupport Courses and International Training Centres at Pune, Mumbai, Ahmedabad, Hyderabad and Bangalore. “More centres are in the pipeline at Delhi, Kolkata, Patna, Jaipur and Chennai,” says Dr Balasubramaniam. It has also established a formal para-medic training programme at Pune and Mumbai using the US department of transportation with the help of Los Angeles County Paramedic Training Center.

Where is the money?

Most EMS facilitiies in the country are crippled by lack of permanent source of funding. "As in the West, funds can be collected as a part of highway toll tax and part of the tax on fuel. As India is reeling under the burden of deaths due to road accidents, some funds can be chipped from these sources," suggests Dr Joshipura. In the US, one per cent of toll tax is reserved for supporting EMS.

While successful EMS facilities in the US and the UK have been extolled as models of success, India cannot replicate them in toto as the economic conditions of the countries are different. Worldwide, efforts are on to build a cost-effective low resource EMS model. A steering committee of WHO is working on devising cost-effective methodologies and high-yield strategy for low-income countries. The WHO has recently released guidelines on pre-hospital trauma care systems. In May 2007 in the World Health Assembly, the WHO will mandate universal EMS service.

Is high cost service feasible?

"Before using high-cost technology on a large scale, India needs to check the effectiveness of it on a smaller scale," suggests Dr Russell. According to Dr Satchit Balsari, Emergency Physician at New York Presbyterian Hospital, "What is key is that we build sustainable infrastructure. Step-by-step expansion will ensure growth and continuity. Additionally, telecommunication and telemedicine should be turned to the advantage of our rural communities."

For instance, think of a well-equipped ambulance many kilometres from the nearest hospital, transporting a patient under supervision of a remote physician who is in communication with the paramedics, directing them through management while directly observing the patient via video feeds. "However space-age and distant this may sound in India, a step-by-step breakdown of the infrastructure will reveal that we already have most of the requisite technology. A robust infrastructure will, in the long-run, ensure an advantageous cost-benefit ratio," says Dr Balsari.

If Indian doctors are receiving international acclaim for their clinical acumen and Indian nurses are valued for their compassion and dedication, then medical care must percolate to the man in need of urgent care. We also need to spare a thought about creating EMS facility in rural India.

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